Deficiency Records for Breezy Hills Rehab and Care Center
Updated as of October 01, 2020
This is not the most recent data for Breezy Hills Rehab and Care Center. For the most recent information, click here.
A list of the most recent deficiencies for Breezy Hills Rehab and Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
---|---|---|---|---|
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2020-01-13 | 2020-02-07 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-25 | 2019-12-23 | Y |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-09-19 | 2019-10-14 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-19 | 2019-10-14 | Y |
Be properly staffed | Fire Safety | 2019-08-07 | 2019-09-09 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-07 | 2019-09-09 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-09 | 2019-09-09 | N |
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2018-11-19 | 2018-12-17 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-19 | 2018-12-17 | Y |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-11-19 | 2018-12-17 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-04-19 | 2018-07-17 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-04-19 | 2018-07-17 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2018-04-19 | 2018-07-17 | N |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-04-19 | 2018-07-17 | N |
Address subsistence needs for staff and patients. | Fire Safety | 2018-04-16 | 2018-05-11 | N |
Implement emergency and standby power systems. | Fire Safety | 2018-04-16 | 2018-05-11 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-16 | 2018-05-11 | N |
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-04-16 | 2018-05-11 | N |
Be properly staffed | Fire Safety | 2018-04-16 | 2018-05-11 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-04-19 | 2018-05-11 | N |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-04-19 | 2018-05-11 | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-04-19 | 2018-05-11 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-03-04 | 2018-03-28 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-04 | 2018-03-28 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-03-04 | 2018-03-28 | Y |
Provide and implement an infection prevention and control program. | Health | 2018-03-04 | 2018-03-28 | Y |
Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2017-07-31 | 2017-09-06 | Y |
Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-07-31 | 2017-09-06 | Y |
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2017-03-28 | 2017-04-26 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2017-03-31 | 2017-04-26 | N |
Ensure that residents are safe from serious medication errors. | Health | 2017-03-31 | 2017-04-26 | N |
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-03-31 | 2017-04-26 | N |
Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-31 | 2017-04-26 | N |
Keep all essential equipment working safely. | Health | 2017-03-31 | 2017-04-26 | N |